Create a 1 Page Medical History That Will Empower You and Help Your Doctor Listen (Free Downloads)

Even though I was once a family doctor, it wasn’t until I developed a chronic illness and started having to make frequent office visits as a patient that I realized I needed an easy-to-read summary of my history to bring to new doctor appointments.

This was partly because I didn’t remember every detail about all of my symptoms, past diagnoses or tests, or medications. It was because my mind wasn’t always sharp when I wasn’t feeling well.

I was also motivated by the fact that office visits with new health care professionals could be quite stressful since I didn’t know how I’d be received.

Even though I’m a doctor, that doesn’t always mean much, especially if you have symptoms that are difficult to diagnose or for which no diagnostic tests exist (I have chronic fatigue syndrome, also known as myalgic encephalomyelitis or ME/CFS).

Finally, it was because I got tired of hand-writing the same summaries and notes every time I scheduled a new medical appointment.

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Knowing from personal experience that doctors can get overwhelmed when a patient gives them too much information (even during hour-long appointments), I decided to summarize the important stuff onto single pages.

It enabled me to take control of my information, reduce the amount of papers I gave to my doctors, and simplify one small aspect of my chronic illness life.

It also supported me to feel more put-together during appointments, which helped me stay more emotionally neutral, regulated and able to see my doctor as a consultant who was there to help me rather than an all-knowing, all-powerful God.

In short, it was empowering.

This guide will help you create your own one-page medical summary to bring to new doctor appointments, whether you have a chronic illness, have had cancer or a complicated history of medical problems, need a summary for disability or health insurance applications, or are healthy as a horse but wanting to streamline your or your family’s medical records.

Once you have a summary of your medical history it’ll make appointments run more smoothly, especially if your health history is complicated.

It can also help your doctor listen more fully to the details you have to add, as well as see and feel how you are invested in your health and that you are together in this and part of the same team.

It might even put a smile of appreciation on your doctor’s face.

The One Page Summary

One common reason for seeing a doctor, especially if you have a chronic illness or other long-term health problem, is to get help in diagnosing and treating symptoms as efficiently as possible, so you can find the best treatments available.

Summarizing your history in an easy-to-read, one-page format is a helpful way to give your doctor a quick overview of the whole picture (here’s a helpful New York Times article on “Advice from Healthcare’s Power Users” that includes many practical and informative additional tips in the comments).

A summary includes your:

• present symptoms
• work-ups and test results you may have done so far
• relevant past
• potential risk factors
• possible contributions from family history
• medications

This gives your doctor some context and helps them hone in more intelligently on your main problem. There are two examples of one page medical summaries in the downloadable guide.

If you are pretty healthy, one page is all you will need to summarize everything. Even if you have one or more chronic illnesses or a history of complex health problems, however, it’s still possible to summarize important parts of your history onto one page. If you do have a long medical history, however, you may find it helpful to make other one-page summaries (I introduce this in an appendix in the free guide).

The same summary can be helpful if you’re going in for a medication refill or for your annual exam.

To start, then, you’ll want to create a one page summary of your health history. This is the focus of today’s post.

Since most of us see a doctor from time to time, I’ll keep things simple by using the term “doctor” to represent all health care professionals throughout the rest of this post.

Make it Easier for Your Doctor (and Therefore for You)

Tips for making it easier for your doctor include:

• keeping it to one line per topic (such as one line per medication, diagnosis or procedure)
• using a specific order, which I’ll show you below
• making it no longer than a singe, one-sided page (too much information can be overwhelming)
• using a normal-sized font to make it easy-to-read (I use Times in 12 point font)

Step 1: Gather Information & Prepare

Go through the steps below starting with what you know rather than with pulling together all your medical records. It’s generally what we already do as we fill out forms at new doctor appointments and when our doctors gather our medical histories by asking us questions.

What you remember is likely more than enough to create a well-rounded one page summary of your medical history.

Next, give yourself the time you need so this can feel supportive and empowering rather than overwhelming.

Going through your medical history can feel like you are rummaging through every bad thing that’s ever happened to you, and can therefore be stressful and emotionally difficult.

So take your time, take breaks and pace yourself. If you have a complex history, this process may take a few days or weeks rather than a few hours. That’s often the kind of time we already spend preparing for new doctor appointments and it adds up when there are lots of new medical appointments.

Because I have a chronic illness with a number of complicated symptoms, for example, it took some time for me to create my summary.

When I first made my own one pager, I spent a few hours a day for probably a week thinking things through and figuring out what to put in (and what to leave out) of my one page summary. But that was the largest time investment I ever had to do.

I now spend 10-15 minutes updating it before a specific doctor’s appointment (often less, sometimes a little more if a lot has changed and because I’m one of those people who really likes organizing information and pulling all the little details together).

You can get support by getting help from a friend or family member or even collaborate and create your one-page medical summaries with them.

Just remember, there is no perfectly right way to do this.

No history you’ll ever give is likely to be exactly the same, and if 10 different doctors were taking notes while you spoke, each one would summarize your history slightly differently.

Figuring out what’s important, relevant and how to be succinct takes time and that’s completely normal.

Step 2: Use These Categories, In This Order

When doctors are trained in medical school, we learn a methodical approach for gathering a patient’s history as a way to keep it in order in our minds. It also helps us make sure we cover all the important parts.

Creating your form in this order makes it easier for your doctors to tuck important pieces of information into the back of their minds while they work on helping you solve your problem. This is an especially good format for new doctor appointments when your full history is needed, such as for a a first visit with a new specialist and a new patient exam, etc. I’ll help you see where to stash little extra bits of information into this framework later on.

Start here and include a line for each event, symptom or diagnosis that fits under the appropriate category.

You can also download a free formatted document to use in microsoft word and start entering your information in that form if you like.

Chief Concern. Also called the “chief complaint” or “presenting problem” by doctors: what symptoms or issues are you most needing help with?

History of Present Illness. More details about your chief concern (symptoms, test results if you have any, when it started, etc). This category is optional since the doctor will ask you for more details about your concerns.

Medical History. Where you list your diagnoses, medical problems and hospitalizations. Anything surgical goes in the next category.

Surgical History. Summary of operations and procedures you’ve had. Include the type of anesthesia if you have room (local, general, spinal, epidural etc) and any complications or problems you may have had.

Reproductive History. This section is for women to document any difficulties with menstrual cycles, pregnancies and births, postpartum events such as depression, symptoms or date of onset of menopause, pain and anything else related to the reproductive system. It’s not usually part of a doctor’s history in this order but is so common in many women that I’ve included it here. If you have no concerns in this area, you can leave this entire category out.

Medications and Other Treatments. Prescribed and over the counter (OTC) meds (herbs, vitamins, supplements, etc). This area is usually specific for medications only. I also use it to present other things you may be doing for your health that are useful for your doctor to know (and that can also convey personal motivation, involvement and investment in your health). Dietary changes, physical therapy, acupuncture, mind body approaches such as meditation can all go here.

Allergies. A list of life-threatening allergies to medications. Include the symptoms you’ve had that made you realize you have an allergy such as a rash, chest tightness, trouble breathing etc. If you have room you can include any severe food, insect, latex or other life-threatening allergies.

Social History. Your occupation, education, and relationship status (married, single, widowed, etc), or you could refer to your “social support network,” which does not require marriage to be strong in your life. What you’ve done or had for prevention, such as vaccines, screening tests such as mammograms, pap smears, prostate exams. Any life-style risk factors such as smoking, alcohol, etc… This is a place to mention emotional or physical trauma if it has played a role in your symptoms and you’d like your doctor to know (The step-by-step downloadable guide describes pros and cons for doing this and how you might education your doctors and cite a landmark research study on your form).

Family History. Health problems or chronic illnesses in siblings, parents, grandparents & other close relatives.

Step 3: How to Fit It On To One Page

If you’ve completed the steps above and it all fits onto one page you are good to go. If you’d like to make it as easy and quick as possible for your doctor to scan you can get additional tips in the step-by-step guide).

Because I’ve had a chronic illness for 20 years, I find that once I’ve filled in all the categories above it is another step in the process to pare down my detailed medical history to one page. This additional step can take a little extra time and that’s normal.

I start by seeing how many lines I have gone over the first page and onto a second. If I have 2 whole pages of information, it indicates that I probably need a separate one pager for the topic that takes up most of the space (medications? labs and test results? a chronic illness?). That’s something you can create if you have the energy and interest, at some point.

If I just have 4 to 10 lines on the second page, I know I should be able to make it fit. And I know just how much space I need to create.

So I start with whichever category feels easiest to me. Family history, for example, can be a place to shorten with relative ease. Maybe you can fit both of your parents’ health onto one line instead of two. The same with other family members as you decrease some of the detail you initially provided.

This is also where you might be tempted to use abbreviations. If you’re comfortable with them, use them. Or you might find other language to use instead of the words you first chose (“mammogram ok” instead of “mammogram normal” can save just enough room to fit your info onto one line instead of two). If not, consider leaving a few details out instead. Your doctors can always get more information from you if they want it.

This part can feel fussy or finagle-y but it’s what creates an easy-to-read summary that is quick and easy for your doctor to scan. Stay with it. And if you need help, ask someone you trust, such as a compassionate family member, friend or colleague to see if they have ideas for making it shorter or easier to skim.

Example:

The longer, slightly more detailed version could like this:

Parents      Mother (72yo) in good health

Father        Died of a heart attack age 56yo, was smoker, had diabetes type 2 x 20 years

Brother     MS, dx 54yo, stable on meds, works full-time

Sister         Depression, PTSD after military service, on rx, better after trauma therapy

You could shorten it to look like this instead:

Parents     Father died heart attack (56yo), smoker, diabetes type 2 x 20yr; Mother healthy (72)

Siblings     Brother, MS, dx 54yo; Sister, depression, PTSD (veteran), on rx, therapy helping

Remember that you don’t have to include everything that has ever happened to you. Your doctor can ask and you can tell them there’s more.

Once you’ve got it all shortened down to one page, your one page medical summary is good to go!

Step 4: How to Use Your Summary At New Doctor Appointments

I bring 2 copies of my medical summary to new doctor appointments, one in case the doctor is interested (not all of them will be) and one for me to help me remember details.

I like to wait until I meet and start talking with my new doctor before handing it over. When they ask why I’m there to see them I tell them very briefly and explain that I have a one page summary of my complex medical history. I ask if they’d like to see it:

I’m here because I’ve had problems with fatigue for the past 6 months. My family doctor has done an initial work-up but the medications we’ve tried aren’t helping and I need a deeper investigation. I’ve summarized some of the results and my medical history on a single page, would you like to see that?

You could tell the receptionist when you first check in or the nurse who checks you in that you have a summary of your medical history and ask if they’d like to attach it to your chart for your doctor to review before the appointment. Since most doctors don’t have any extra time to review much if any of your chart before they step in to see you (there’s no such timeline built in to doctors’ schedules unless this is something they personally include in their routine), I prefer not to add anything to their chores before they see me.

I like to be there when the doctor scans the document. That way I can answer questions if they have any. I also get to see how they react (interested? curious? overwhelmed?), and adjust my responses accordingly, such as waiting quietly while they read it, making more effort to keep things short and non urgent if they seem overwhelmed, and staying as open as I can to following their lead if this doesn’t seem to be the way they like to gather information.

Having my summary in hand also helps me remember that I am already whole, that I am okay just as I am (even if I’m sick, it is not WHO I am), and that I am just as “valid” a person as my doctor is. Having my medical history summarized and in hand helps remind me that:

• I am there to consult someone for specific skills (western medicine rather than an all-knowing “God”)
• They will probably not have all the answers even as they might be able to assist me on my quest for better health.
• Even though I need their help (and I may have significant feelings of desperation or urgency because of how sick I might be), I have choices in who I see and how I act.
• Their questions can inform me about details that might be useful to include on my form with future new doctor appointments (such as certain lab results, for example).
• I can assess how I feel about this particular doctor. How well do they listen? How do they respond to my own investment of time and will power and participation, such as major changes in diet or daily meditation? Are they open to my contributions, such as the research on trauma as a risk factor for chronic illness (and not just for mental illness)?
• I have a tool with me that helps me stay as empowered as possible.

Take your time. Remember to take breaks. Get support. And leave your questions in the comments below.

If you have one or more chronic illnesses or a complicated medical history and you’ve downloaded the guide, followed the step-by-step instructions and are still having trouble fitting it all onto a one page summary, let me know.